2/23/2018 SesamoidDisorders: Painful for Everyone...2018/02/09 · –Avgf/u of 35 months •22/24...
Transcript of 2/23/2018 SesamoidDisorders: Painful for Everyone...2018/02/09 · –Avgf/u of 35 months •22/24...
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Sesamoid Disorders:Painful for Everyone
Gregory C Berlet, MD FRCS(C), FAOAOrthopedic Foot and Ankle
Columbus, Ohio
Columbus, Ohioorthofootankle.com
Robert B Anderson MDTitletown Sports Medicine and Orthopedics
Green Bay Wisconsin
Disclosures
• Consultant/Speaker Bureau/Royalties/ Stock: Wright Medical, Stryker, ZimmerBiomet, DJO, Plasmology4, Amniox Medical, United Orthopedic Group, Paragon 28, CrossRoads, Ossio
20 year old Female
• Colleagiate soccer athlete
• 6 month history of pain in the ball of her foot
• Swelling, pain and inability to run
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Clinical Findings
• Pain localized to tibial sesamoid
• Some local swelling
• Good ROM and stability
Fracture or Bi‐Partite ?
Bipartite:
– 20‐40% incidence– Bilateral 60‐80%
Fracture:
– Tibial >Fibular– Larger and more prone to injury
Fracture vs Bi‐Partite
• Fracture tends to be at the waist, jagged edges
• Bipartite often rounded sclerotic edges and may be distal or proximal 1/3
• Comparison views helpful
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MRI / Bone Scan / CT
Cold and No Edema = Bipartite
Tibial Sesamoid Stress Fracture
• Young athlete
• Fairly profound disability despite 6 months non operative care:
– Boot walker x 2 months
– Orthotic with mortons extension
– Attempt to return to sport failed
Audience Poll: Recommendations for Tx
1. Further immobilization
2. Sesamoid ORIF
3. Sesamoid bone grafting
4. Partial sesamoidectomy
5. Medial sesamoidectomy
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Operative Treatment Indications
• Failure of conservative treatment
• Pain/tenderness ‐ localized to one sesamoid
• Diagnostic studies identify abnormality that correlates with pain
Partial Sesamoidectomy
Biedert et al (2003):
• 5 pts with proximal pole sesamoidectomy for non‐union
• 100% good to excellent, one with restriction of sports activities
Anderson ( personal communication):
• Perform for fractures <25% of total
Bierdert R, Hintermann B: FAI 24(2), 2003
Our Choice: Sesamoid Bone Grafting
Why ?
• Sesamoid stress fracture nonunion
• Fragments healthy
• Minimal diastasis
• Young patient
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Sesamoid Bone Grafting
• Medial approach
• Fracture identified on plantar surface after plantar shaving
• Articular surface intact
• Local bone graft
• No internal fixation
Sesamoid Bone Grafting
Tips and Tricks:
• Plantar shaving to decrease plantar load and expose the fracture
• Local bone graft from metatarsal head
Sesamoid Bone Grafting
Anderson/McBryde (1997):
• 21 tibial hallux sesamoid stress fracture nonunions
• 19 radiographically healed
• Avg. 12 weeks to union
• 20/21 returned to athletics
Anderson RB and McBryde A: FAI 18(5), 1997
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Sesamoid Bone Grafting ‐ Example
• Postop CT–Union at 16 weeks
Our Patient
• Healed CT at 12 months
• But… continued pain
• RBA: “ majority of patients received concomitant relief of symptoms”
Anderson RB and McBryde A: FAI 18(5), 1997
Our Patient
• Healed CT at 12 months
• But… continued pain
• RBA: “ majority of patients received concomitant relief of symptoms”
Anderson RB and McBryde A: FAI 18(5), 1997
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Persistent Pain
Differential Diagnosis:
• Plantar plate ligament instability
• Sesamoid arthritis
• Sesamoid instability / Bunion
• Lateral sesamoiditis / fracture
Back to Some Imaging
Pre bone grafting
Now
My Plan
• Medial sesamoidectomy
– Remove the pain generator
• DSTP
– Balance the lateral sesamoid back into the cristae
• Reconstruct the medial plantar plate
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Consequences !
• Effect of sesamoidresection on FHB push‐off strength
– Tibial: 10%
– Fibular: 16%
– Both: 30%
Apner RL, Saltzman DL, Brown TD: FAI 15(9), 1994
Sesamoidectomy Approach
• Goal: Preserve or restore the anatomy
• Tibial: medial approach
• Fibular: plantar approach
Medial Sesamoidectomy
• Medial approach
• Identify and protect medial plantar nerve
• Protect FHL centrally
• Shell out from plantar
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Reconstruct the Defect
• Abductor HallucisTendon Transfer
• Transfer into defect
• Secure to the proximal phalanx base
Indications for Abd Transfer
• Large defect that cannot be primarily closed
• Concern about hallux valgus
• Need for flexion power
Surgical Technique
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Good not Great Operation
Sesamoidectomy Results:
• Mann et al, 1985
• Leventen, 1991
• Brodsky, 1991/1999
• Mann and Coughlin, 1993
• Lee et al, 2005
Athletes and Sesamoidectomy
Bichara et al (2012):
• 24 medial sesamoidectomies– Avg f/u of 35 months
• 22/24 returned to sporting activities– Average of 11.4 months
• Mean pain improvement from 6.2 to 0.7
• One patient developed hallux valgus
Bichara DA, Henn RF, Theodore GH: FAI 33(9), 2012
Deformity after Sesamoidectomy
• Nayfa et al ( 1982):–19 tibial sesamoidectomies–8 of 19 (42.1%) developed a hallux valgus
deformity (post-operative Δ of HVA >8°)
–Recommended an adjunctive procedure when performing a tibial sesamoidectomy
Nayfa TM, Sorto LS: JAPA 72(112), 1982
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Postop sesamoidectomy
• Non‐WB x 2 weeks
• Maintain hallux alignment/protect in boot for 6‐8 weeks
• 3months – orthosis/tape protection for recreation
Our Patient
• Pain reduction is significant
• Bunion is improved
• Return to sport at 6 months
Sesamoid Fractures
Take Home Points:
• Imaging helps distinguish between bipartite and fracture
• Don’t be quick to operate
• Partial sesamoidectomy only for small proximal pieces (<25%)
CONCLUSIONS
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Sesamoid Fractures
Take Home Points:
• FHB must be restored for power and balance
• In medial sesamoidectomy consider abdhallicus transfer
• Do not overpromise with sesamoids – a good operation , not a great one !
CONCLUSIONS
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